of 1896 The day before the operation the patient is 5. Patients quickly revive when given fresh air, subjected to a thorough examination, when the condi❘ without the use of drugs.- Medicine. tion of the heart, lungs, and kidneys is noted. A warm bath is given to stimulate excretions.-In order to have Necrosis of Pancreas.-Morian (Prager Med. the alimentary tract in the best possible condition the Woch.; Brit. Med. Jour) reports a case in which, judg diet is limited to liquids, and one or two ounces of casing from clinical symptoms, he operated for cholelithi tor oil is given, to be followed the next morning by a asis. Some coils of the intestine exposed during the warm enema. The face is anointed with vaseline, a operation bore small yellow growths which made him thick pad of moistened cotton placed over the eyes, suspect that tuberculous peritonitis was the real malady and anesthesia commenced, the patient being itstructed from which the patient was suffering; nevertheless he to count after the anesthetist. The inhaler used is the opened the distended gall bladder. Many calculi were Esmarch mask covered with three or four layers of extracted, with much serous fluid. The patient con. gauze; the same mask is used for chloroform and ether, tinued to show symptoms of sepsis, as before the operand the drop method is always employed. Chloroformation. is given until the patient is asleep or insensible, when ether is substituted. If, however, at any time during the administration of the chloroform the breathing be comes shallow, or the heart embarrassed, the chloro form is stopped altogether, suspended for a time, or a few drops of ether given with the chloroform. The two anesthetics are kept in separate bottles; in this way the exact amount of each can be regulated according to the discretion of the anesthetist, which is a great ad vantage. The simple Exmarch mask is superior to any other for ether, as well as for chloroform, as it allows of an abundant mixture of air, which avoids danger, and pa tients do not become so thoroughly saturated with the poison; consequently lung and kidney complications are decreased, and there is less retching and vomiting afterward. No drugs are ever used either before or after the anesthesia. As soon as sleep is induced the lower jaw is hooked over the upper and held in this position. We deprecate the use of gags, because they throw the jaw backward, the very thing to be avoided. The head should be on a level with the body, a small hard pillow being preferable to a feather pillow. The patient is not removed to the operating table till thor oughly asleep, and this is done as gently as possible. The pupilary reflexes are an infallible guide to the degree of narcosis. No attention is ever paid to other reflexes; touching the cornea is unscientific and tells nothing. A contracted immovable pupil teaches us that we have surgical narcosis, a dilated immovable pupil is a danger sign, while a dilated pupil which re acts to light shows only partial anesthesia. In the one thousand cases artificial respiration was performed six times, Sylvester's method being used. The author comes to the following conclusions: 1. If anesthetics are carefully given, according to the method described, difficulties of any kind are experienced in only a small proportion of cases. 2. A dilated immovable pupil is a sign of danger before heart or respiration show any change. On the fourth day a swelling developed in the neighborhood of the ensiform cartilage; it was punctured without any result. On the fifth day a coffee ground substance with milk and air escaped suddenly from the opening made into the gall bladder, naturally giving rise to a suspicion of perforation of the gall bladder. The patient lived till a month after the operation. At the necropsy, necrosis of the pancreas was discovered, and a retroperitoneal abscess reached to the psoas. In only 7 cases has pancreatic necrosis been discussed, and only 1 lived; in that instance there was diabetes. Pancreatic Cyst in Lesser Omentum.— Payr (Wien. klin. Woch; Brit. Med. Jour) relates a cese where the cyst of the pancreas occupied a most unusual position, very puzzling to the opertor. The patient was a lad, aged 19, and after a blow in the epigastrium from the handle of a bicycle, a tumor developed in the upper part of the abdomen. On tapping the fluid was found to contain a ferment which saccharized starch. An exploratory incision was male. The cyst was found with the left lobe of the liver forming its capsule above, whilst the stomach lay entirely below it, Payr making out that the two layers of the lesser omentum invessed the back and front of the pancreatic cyst, meeting underneath it, to be reflected (in the normal manner) on the back and front of the stomach. Payr considers that acute traumatic pancreatitis had been caused by the injury; a cyst developed on the upper part of the damaged organ, and dissected up the parietal peritoneum till it reached the under surface of the liver; then it insinuated itself between the sub. stance of the under surface of the liver and its closely adherent serous investment, finally reaching the transverse fissure, when it easily opened up the lesser omen. tum. Not only was that fold traced underneath the immediately in apposition with the cyst wall. Extircyst, but Payr declaref that the liver substance came pation was out of the question, so close were the relations of the cyst: excision and drainage were, there fore, practiced, the patient recovering The pancreatic 3. The Esmarch mask is superior to any other for cyst in this case occupied a position in relation to the ether. 4. The method described requires less anesthetic and a shorter time for induction of narcosis. peritoneum higher than has ever previously been recorded. It had pushed itself out of the lesser into the greater peritoneal cavity. In Heinricius' case the cyst pushed forward the parietal layer of peritoneum below the descending layer of the transverse meso. colon, so as to lie in the greater and entirely below the lesser cavity. In the great majority of cases of pancreatic syst the tumor lies in the lesser cavity. store the circulation by hot salt bags. We do not know of any other instances in which this has been done in the attempt to restore severed parts. To what extent it is useful it is difficult to say; at any rate, it is rational. Several cases of union of severed finger tips are re root of the nail. The raw surfaces were freshened and the tips were attached each by four sutures. Dr. Finney used antiseptic dressings, but not solutions, because bichloride of mercury and carbolic acid produce a thin layer of coagulation necrosis. The wounds united by first intention. The Pancreas in Congenital Syphilis.-corded. In the Johns Hopkins Hospital Bulletin, Octo Schlessinger (Virchow's Archiv; Brit. Med. Jour) is ber-November, 1892, Dr. Finney has published a case aware of the rarity of syphilitic affections of the pan. of successful suture of severed finger-tips after seven creas when the disease is acquired. Petersen found hours. The middle finger was cut off just below the that organ specifically affected in one subject only out last joint through the phalanx, the ring finger at the of 88 necropsies on patients who had died with symp toms of tertiary syphilis. On the other hand BirchHirschfeld, as long ago as 1875, described syphilitic disease of the pancreas in new born children and in fants. Schlessinger describes six such cases from Von Recklinghausen's wards, in which death er sued in every instance, and the viscera were carefully examined. He concludes that in congenital syphilis the pancreas is less often affected than the spleen, liver, bones, and lungs, but more frequently than the thymus, heart, in testine, and other viscera. The organ in question may be attacked very early, even in the fifth month of uterine life, or not till near or after birth. Its diseased condition is not uniformly associated with changes in neighboring organs, though the duodenum is occasion. ally involved. Gummata, great and small, are excep tional; this is contrary to the rule in acquired syphilis, where the pancreas, in those rare cases when it is in. volved, usually contains gummata. Peritoneal adhesions are not rare in congenital cases. The pancreas does not seem much enlarged, but it is always abnormally firm in consistence, so as to feel in typical cases as tough as cartilage. The head is always more affected in this way than the tail. The disease in question is essentially diffuse interstitial pancreatitis. The interacinous tissue increases rapidly, beginning chiefly round the vessels, themselves affected with peri arteritis and endarteritis at an early stage. The smaller and the main ducts are but little affected, but the pro liferating tissue undergoing sclerotic changes, the glandular elements of the pancreas are soon irretievably damaged. In all Schlessinger's six cases other organs were diseased, and osteo chondritis was noted as exist ing in four. In a recent number of the New York Medical Journal appears an account of the following case, published in the Louisville Medical Monthly by Dr. John Cook Laurens: A colored man in using a heavy axe cut through his shoe and severed the metatarsal bone of the first toe through the head, completely disarticulatthe toe, and also cut off the second toe in front of the metatarsal joint. He was seen four hours afterward. The shoe and sock were cut away and the second toe was found separated, whilst the first was hanging by a mere string of skin, every muscle and vessel being cut. They were united by interrupted sutures which included the tendons. A dressing of iodoform and boric acid, equal parts, was used and a splint was applid. The iodoform had to be discontinued because it proved irritating. Union by first intention occurred over more than half the wound, and there was but litt'e pus where granulation took place. On the third day sensibility was present in both toes, and in a week the patient could move them a little. Finally they were strong, movable, and sensible, and except for a little tenderness. of the foot was as good as ever.-The Lancet. OBSTETRICS AND GYNECOLOGY. Treatment of Extra-Uterine Pregnancy. Restoration of Severed Parts.-The possi--Segond, of Paris (La Med. Rev.), says: In the treatbility of restoring severed parts, even under unfavorable ment of extra uterine pregnancy of less than five months circumstances, is not so generally appreciated as it the entire removal of the fetal sac by abdominal section. should be, and attempts which might be successful are not made. Lately we published three cases in which the severed external ear was successfully replaced. In one (Dr. Brown's) the circustances were anything but encouraging. The ear had been bitten off by a horse and was found lying in a stable yard. Neither surgical instruments nor antiseptics were available; a common needle and thread had to be used. In the other two cases (Dr. Purcell's) the surgeon adopted the ingenious plan of keeping the ear warm and endeavoring to re is the method of choice. Ablation by anterior or pɔsterior colpotomy has been done with success but it is much safer to remove it by laparotomy. In the treatment of ectopic pregnancy of less than five months, complicated by hemorrhages which vary in degree from an hematosalpinx to a profuse abdominal hemorrhage, laparotomy is the only operation that permits of certain hemostaxis in these conditions when rapidity and security are especially desirable. In the treatment of septic or suppurative complica tions the vaginal incision is without question the treat ment of choice for suppurative hematocele if the entire purulent collection is limited, unilocular, and easily accessible through the vagina. Vaginal hysterectomy is the best operation when there are bilateral lesions of the adnexa, when the duration of the pregnancy does not cause the fear of a large placenta, and when the size of the mass to be removed has not become too large. Removal by laparotomy remains the only rational oper. ation when there is doubt that the lesions of the appen dages are other than that of ectopic pregnancy, when pregnancy has passed the fourth month, and when the size of the mass to be removed seems to be more abdominal than pelvic. In the treatment of extra-uterine pregnancy of more than five months, except for certain fetal cysts, laparotomy is therefore the only procedure proper. turn, also, suppurative peritonitis demands prompt operation without modifying very much the method of procedure. In pregnancy with recent 'death of the fetus it is prudent to await until the oysto-placental circulation is diminished and to postpone operation; in this condition, however, the delay should never be longer than six weeks. It is very important not to await until the menses have returned and the risks of rupture by hyperdistension of the sac of which they are generally the signal. The same comparison is met with in the treatment; elytrotomy is to be avoided. Attempts at ablation lead to risks so great that, but for the exceptions already mentioned it is necessary as a general rule that intervention be limited to the extractioe of the fetus, shutting the sac off from the peritoneal cavity and leaving the placenta to be spontaneously detached. In pregnancy, where the fetus has long been dead, it is serviceable and becomes a good operation; when the fetal sac is low down in the pelvic cavity as to be easily accessible through the vagina, and when the placenta is not inserted on its inferior surface. Shutting off of the sac from the abdominal cnvity remains the operation of choice in the majority of cases, and moreover, the results are better than where removal of the placenta is indicated. Partial extirpation of the sac can be made where adhesions are not numerous; with the remainder of this membrane a sac of smaller size should be made with a counter opening through the vagina for drainage. This procedure has the advantage of permitting the closure of the abdominal wall and of preventing possible hernias. This method may be employed when the fetus is free in the abdominal cavity, the sac is then When is it necessary to operate? Beyond question, when the child is at term. When the fetus is living, but not yet viable, or when it is viable but not at term the responsibility is more delicate. When a fetus is living, but there remains several weeks before the earliest date of viability, the dangers to be risked are too great and immediate operation is indicated. When, on the contrary, it is almost to the period of viability, an attempt should be made to save the mother and the child until that stage is reached, although the safety of the child never withdraws the shadow of peril from the life of the mother. The expectation being decided in these conditions, is it necessary to operate in the seventh month or indeed await until the eighth or ninth month? In regard to waiting, if the mother is in per fect health, and without there is a slight suspicion of danger for her that requires us to take immediate ac- diminished to only cover the placenta. But it is better tion, it is better to await for the fetus to develop as much as possible. On the whole, unless it is possible to to be very certain, it is well to leave to circumstances to indicate the best time to intervene. to remove the placenta and all the membranes and the peritoneal toilet made as complete as possible; when this has been satisfactorily accomplished the abdominal wall may be entirely closed without drainage. How to operate? Elytrotomy should be entirely re- When the fetus is in a complete sac, total extirpation jected. The only operations possible are: abdominal of the cyst is most often permitted than with a fetus opening of the sac leaving the placenta in situ; opening living or recently dead. In the case of abdominal rewith removal of the placenta; entire removal of the moval of the uterus and appendages, entire, it is, in this fetal sac. As a general rule intervention may be limited particular instance, a large and dangerous operation, to opening of the sac, extraction of the fetus leaving the the indications for which, being limited, may be summed placenta behind. To this rule there are three excep-up in the following manner: It should he especially tions; the first, those cases of tubal pregnancy than can reserved for cases where entire removal of the fetal sac be easily enucleated demand entire removal; the second having been commenced and it is found impossible to is met with when there is a hemorrhage from a partial detachment of the placenta, when complete removal is necessary in order to arrest the hemorrhage; the third, when there is a rupture of the sac and the fetus is free in the abdominal cavity. In the treatment of ectopic pregnancy of more than five months, complicated by hemorrhage from rupture or by suppurative peritonitis, the hemorrhage from rup ture demands immediate operation. Opening of the cyst should be attempted but the difficulties of hemos tasis often compel the use of more radical measures and especially the complete removal of the placenta. In its detach it without long and difficult manipulations which the resisting power of the patient might not be able to withstand. It may be greatly simplified by making a large subpubic opening for drainage. For reasons of a different nature the tubo-interstitial pregnancy or the presence of a concomitant uterine neoplasm are each unquestionable indications for abdominal hysterectomy. An old ectopic gestation, without rupture, or even where it has suppurated, does not demand special methods for extraction. It may be complicated by suppurative peritoneal lesions that demand urgent laparotomy and they are to be treated by total extirpation or by guide. The patient ought to be kept in bed at least three weeks after the pulse has become normal. The Physician and Gonorrheal Patients medizinische Wochenschrift; International Med. Mag.), in answering the query, "What shall the physician say to a gonorrheal patient who desires to marry," sums up the question as follows: partial ablation with drainage. Generally it is the fetal cyst that gives rise to all the symptoms and may termi nate in one of three ways. Either the cyst has the same characteristics as a relatively movable tumor of the appendages. It is then amenable to the operative Who Wish to Marry. - Kromayer (Muenchener procedures recommended for treatment of ectopic preg nancy where the fetus has long been dead. Or the cyst may be easily opened by an incision through the abdominal wall or through the vagina when it distends one of the vaginal fornices. Or, finally, the cyst may rupture spontaneously through the abdominal wall, through the vagina, or into the rectum or the bladder. In the two first instances the pre existing fistula is to be enlarged. In the case of rectal fistula this opening must not be utilized and the mass must be removed through the abdomen or through the vagina. When the fetal sac opens into the vagina the contents may be passed out through the urethra when it contains a very small fetus that has perished before the fifth month, but larger cysts necessitate a more extensive interfer ence as cystotomy or laparotomy. If the presence of Neisser's gonococci is demonstrated, the physician's duty is clear and needs no elucidation. But, if the bacteriological examination is negative, his answer should cover the following pointe: As a negative bacteriological examination is not an absolute proof of the absence of gonococci, it is the patient's first duty to make an earnest and sustained effort to rid himself of the gonorrhea or chronic inflammation of the urethra by a systematic course of specific treatment. This is not to be neglected even in cases where the examination has for a long time repeatedly failed to detect gonococci. If a complete cure is found impossible, or if the pa the physician should explain the case under its various aspects, and leave the decision with the patient. In no case is the physician to assume the responsibility of the gonorrhea not becoming infectious. Thrombosis and Embolism After Child- tient refuses to subject himself to further treatment, Birth.-Singer (Archiv fuer Gynaekologie; Medical Standard) shows that thrombosis and embolish is an important complication of childbirth, and one which is often overlooked. He reports thirty-five instances of its occurrence. From a study of these cases the following conclusions are drawn: If the patient decides to marry, the physician should impress upon him the fact that he is still capable of giv 1. Formation of the thrombus is preceded by an iring the infection, and must, therefore, observe the folregular rise in the pulse rate. This rise is associated lowing rules in sexual intercourse: with the development of the thrombus, and the maximum is reached when the thrombus is completely formed or symptoms develop in the lungs. 2. The curve of the pulse is characteristic. In a typical pulse-curve in thrombosis the pulse rises, while the temperature remains normal. It remains high until the development of edema or a palpable hard cord or symptoms referable to the lungs cause the temperature to rise. If in the next few hours or days the temperature falls the pulse still remains high for some days longer. 4. A variation from this type is found in those patients in whom other causes have produced high temperature before the development of thrombosis. 5. In such cases the thrombus is apt to be an infected one, and the discharges of the patient should be carefully examined in order to ascertain the character of the infection. 6. Such examination will often reveal the presence of gonococci. 7 The good results from the treatment of thrombosis follow its early detection, hence it is of importance to note carefully the pulse curve as well as that of the temperature. 8. Rest in bed is the most important part of the treatment. Above all things the patient must not be allowed to sit or stand up. The pulse is the absolute 1. Urinate immediately before sexual congress to expel any secretion that may have accumulated in the urethra. 2. Avoid as much as possible having intercourse oftener than once a day. 3. Never perform the act twice in succession, because, if the first seminal discharge contains gonococci, the friction attending the second coitus brings them in. to closer contact with the urethra and cervix, thereby increasing the danger of infection. If this rule is disregarded, and the act is performed more than once in twenty-four hours, the vagina should be thoroughly flushed out with a vaginal douche, which should, in general, be employed as often as possible. The Prevention of Conception. - Treub (Centralblatt fuer Gynaekologie; Medical Standard) says that the principle, "No medical treatment without medical indication," does not meet all cases. Cosmetic operations are certainly justifiable. No less so is the proper application of the pessarium occlusivum. This means of preventing conception is absolutely without danger. The danger for nervous persons lies rather in interrupted coitus and in the use of condoms. It is the duty of the physician to warn phthisical, epileptic, and neurotic persons that they ought not to have children. If a physician refuses, on account of Biblical or Talmudic law, to furnish to such persons the necessary know. MISCELLANY Health Reports.-The following statistics con3erning small-pox, yellow fever, cholera and plague, have been received in the office of the Supervising Sur. geon-General of the U. S. Marine Hospital Service dur ing the week ending February 11, 1899: ledge to prevent conception, there is an end of medical An "Osteopathists" Suit Against a Medical Journal.-We glean from New York Medical Journal of February 11, that the following most appro priate and timely resolutions, introduced by Dr. A. M. Phelps, of New York, at the recent meeting of the Med ical Society of the State of New York, were adopted: WHEREAS, We, as regular practitioners of medicine, are opposed to anything which, under color of law, can foster the operations of chrlatans without medical knowledge; and WHEREAS, The class of quacks known as "osteopa thists" have received legislative recognition in several States; and WHEREAS, A certain William Smith, osteopathits, has been denounced, together with his fellow charlatans, by the Medical Age, and now brings suit against both the publishers and editor of the Medical Age for dainages in the sum of twenty-five thousand dollars; THEREFORE, Be it declared the sentiment of the Medical Society of the State of New York that the editor and publish of the Medical Age are entitled to the sympathy of the members of this Society and of all medical practitioners; that we wish them success in repelling this legal assault; that we recognize in their action a valuable effort toward the suppression of such irregularities in medicine; and that we recognize that when the Medical Age takes such a bold stand in op position to quackery it promotes the interest of Ingitimate and honorable medicine and the welfare of humanity. Nitrate of Silver Stains.-A solution of iodine in ammonia water, so called colorless tincture, will remove nitrate of silver stains from the hands, clothing, etc., but owing to the danger of the formation of nitro gen iodide, which is a very powerful explosive, it is not recommended. A solution of iodine in iodide of potas sium dissolved is water is nearly as quick, and quite as effective. Dissolve fifteen parts of iodide of potassium in fifty parts of water, and to the solution add ten parts of iodine. When the latter is dissolved add sufficient water to make five hundred parts. Keep in a well stopped bottle. Treat the spots with this, and after a few minutes with a ten per cent solution of caustic soda, which will remove the silver iodide formed by the first treatment.-National Druggist. SMALL-POX-UNITED STATES. San Francisn |